PER RECTAL BLEEDING

CLINICAL APPROACH

By :Farihah
Raj
Najwani
SIGN & SYPTOMS
CONTENT
EMERGENCY (RED
FLAG SITUATION)
 Blood passes per rectum may be fresh /altered
 When blood is degraded by intestinal enzymes and bacteria, it becomes black
and acquires a characteristics smell
 Such a black tarry stool is called malaena. To have time to turn black before it
reaches the rectum, the blood usually come from stomach/duodenum.
 Recognizable blood may appear in four ways
 Mixed in with the faeces
 On the surface of the faeces
 Separate from the faeces ,either after or unrelated to defaecation
 On the toilet paper after wiping
Blood Mixed With Faeces/ On Surface of Faeces

Blood mixed with the faeces – come

from above the sigmoid colon to give
sufficient time for mixing
Blood on the faeces- usually come from
the rectum or anal canal
Blood Separate From The Faeces

 Blood collects in rectum, irritate it causing urge to

defecate and patient will pass blood with mucous.
 Diverticular disease/angiodysplasia/haemorrhoids
Blood On The Toilet Paper

 Result of minor bleeding from conditions close to anal margin ,such as haemorrhoids or a
fissure.
SIGN & SYPTOMS (Essentials of Diagnosis)

HAEMORRHOID FISSURE (Painful tear/defect)

INTERNAL 1. Tearing pain upon defecation
1. Painless bright red blood per rectum 2. Blood on tissue or stool
2. Mucus discharge 3. Persistent perianal pain or spasm following
3. Rectal fullness/discomfort defecation
EXTERNAL 4. Coincide with large bulky stools /hx of
4. Sudden,severe perianal pain constipation
5. Perianal mass
FISSURE VS FISTULA ?
FISSURE FISTULA
 RED FLAG
1.Melena,
2.Constitutional symptoms,
3.Change in bowel frequency or caliber
 Patients with minimal BRBPR in the following categories should undergo additional testing regardless of age:
 ●Patients with a history of melena, dark red blood per rectum, or postural vital sign abnormalities should be
4.A family
evaluated history of
for upper gastrointestinal a colon
tract pathology first. cancer
Even if a lowersyndrome
gastrointestinal tract source is considered
possible, these patients are more likely to have proximal rather than distal colonic lesions and should undergo
5.Fecal occult
colonoscopy after blood positive
upper gastrointestinal tract investigations.

6.Patient minimal BRBPR that colonoscopy.
at first don’t need
●Patients with symptoms suggestive of malignancy such as constitutional symptoms, anemia, or change in
frequency, caliber, or consistency of stools, should undergo
 colonoscopy/sigmoidoscopy
●Patients with fecal occult blood positive stools are knownbut then
to derive develop
mortality new with
benefit from investigation
colonoscopy. Hemorrhoids do not affect the prevalence of positive occult blood tests
 constitutional
●Patients syptoms
with family histories andpolyposis
suggestive of familial change in bowel
or hereditary nonpolyposishabit –
colon cancer


colonoscopy
syndromes who present with bleeding per rectum should be investigated with colonoscopy.
●Patients with minimal BRBPR who were felt not to require initial colonoscopy or sigmoidoscopy who then
develop new constitutional symptoms or a change in bowel habits should undergo colonoscopy.
 INVESTIGATIONS

 In the absence of red flags, we generally advise colonoscopy for patients with BRBPR who are 50 and
older;
 sigmoidoscopy or colonoscopy for patients 40 to 50 years of age;
 and, for patients younger than 40 years, no further evaluation if a source of bleeding is identified on
physical examination, and sigmoidoscopy (or colonoscopy) if a bleeding source is not identified.
 Patients with recurrent bleeding should undergo colonoscopy at least once and be periodically
reassessed for any change in symptoms or development of red flags.
LABAROTORY AND DIAGNOSTIC
TESTING

LABAROTORY DIAGNOSTIC
 Complete blood count  Proctoscopy

 Ferritin  Colonoscopy
 Sigmoidoscopy
 HOW ABOUT DIGITAL RECTAL
EXAMINATION ?
 IS a step that MUST do in an abdomen examination,
COMMON PRESENTATION
1. HEMORROID (piles)

 Def : abnormal enlargement of anal cushion

 Anal cushion : submucosa layer of anal canal that has rich blood supply with a cavernous
and capillary network of blood vessels (superior rectal venous plexus) covered by a thin
epithelium.
 2 types : external (false) & internal (true) hemorrhoids
 Risk factors : constipation, prolonged straining, irregular bowel habits, diarrhea,
pregnancy, aging, portal hypertension etc.
 Symptoms : bleeding (bright red, after defecation), palpable lump, pruritis, mucous
discharge, pain on prolapse
External Internal

Distal to dentate line Above the dentate line

Covered by anoderm / Covered by columnar

skin epithelium

Somatic innervated Autonomic innervation

Sensitive to touch, Not sensitive to touch,

pain, temperature and pain, temperature and
stretch stretch
2. ANAL FISSURE

 Def : longitudinal tear in the anoderm of the distal anal canal, from anal verge proximally towards,
not beyond dentate line
 Trauma to anal canal lining >> normally heals quickly but it may reopen as patient defecates next
time and cause further pain >> internal sphincter spasm >> more tearing & decrease blood flow
>> fibrous & does not heal >> chronic anal fissure
 Location : posterior (commonly seen ; male, constipation, diarrhea) / anterior ( female, vaginal
delivery) / mixed / atypical (Crohn’s Disease, TB, HIV)
 2 types : acute (<6 weeks) & chronic (>6 weeks) anal fissure.
 Symptoms : severe anal pain a/w defecation, bleeding on wiping, constipation
 In chronic case ; hypertrophied anal papillary internally, sentinel tag externally, itchiness (d/t
sentinel tag), discharge
 NEVER DO SIGMOIDOSCOPY OR PROTOSCOPY IN CONSCIOUS PATIENT
3. SOLITARY RECTAL ULCER
SYNDROME

 Rare condition of young adults (30 – 40 y/o) that linked to rectal prolapse & paradoxical
contraction of puborectalis muscle leads to rectal trauma >> ulceration
 Etiology : repeated episodes of intussception, difficulty in defecation, straining
 Sn & Sx : rectal bleeding, straining during defecation, and a sense of incomplete
evacuation, mucus passage, anal discomfort
 Ulcer lies anteriorly 10 cm above anal verge
 Endoscopic findings : mucous erythema or single/multiple ulcer or polypoid/mass lesion
4. INFLAMMATORY BOWEL DISEASE
 5. Diverticular disease

 Diverticula- (hollow out-pouchings) can occur from the esophagus

to the rectosigmoid junction (but not usually in the rectum)
 Diverticulosis – having diverticula
 Diverticulitis – inflammation of diverticula
 Can divide into:
 Congenital
- All three coats of the bowel are present in the
 wall of the diverticulum, e.g. Meckel’s diverticulum (true diverticulum)
 Acquired
-There is no muscularis layer present in the
 diverticulum, e.g. colonic diverticula(pseudo diverticulum)
 a) Colonic diverticulum

 Colonic diverticulosis in general is an acquired disease, developing as mucosal and

submucosal herniated through the circular muscle layer at vulnerable weak points of the
colonic wall where the blood vessels penetrate bowel wall.
 Etiology:
1. Low dietary fiber  constipation  Inc. intraluminal pressure
2. Aging  altered collagen structure
3. Connective tissue disease  altered collagen structure
 Symptoms (usually asymptomatic)
 Distension, flatulence and heaviness in lower abdomen
 Pain due to inflammation (diverticulitis)
 Painless hemorrhage – artery eroded in diverticula mouth
 b) Meckel’s diverticulum

 a persistent remnant of the vitellointestinal duct.

 found on the antimesenteric side of the ileum, commonly at 60 cm
from the ileocaecal valve and is classically 5 cm long.
 Posses all three coats of intestinal wall and has its own blood
supply (obstructed and inflamed)
 Its searched when a normal appendix is found upon surgery for
suspected appendicitis.
 Presented as severe hemorrhage, intussuseception, diverticulitis,
intestinal obstruction.
 Tx: Meckel Diverticulectomy
 6. Polyps

 The term ‘polyp’ is a clinical description of any protrusion

of the mucosa.
 Polyps can occur singly, synchronously in small numbers or
as part of a polyposis syndrome.
a) Familial adenomatous polyposis
Clinical Presentation
 >100 adenomatous polyps all over colon, takes 5-6 years to
turn into malignancy Loss stool
 80% of cases come from patients with a positive family Lower abdominal pain
history ( mutation at germline of APC gene on short arm of
Diarrhea
chromosome 5.
Passage of blood and mucus
 FAP is inherited as an autosomal dominant condition and is
consequently equally likely in men and women Weight loss
 Hematochezia vs melena

HEMATOCHEZIA
MELENA
 is the passage of bloody stools, where the
blood appears fresh and red to maroon in  is the passage of black, tarry stools which is
color. indicative of blood that has been undergo
action of degradation, oxidation
 sign of bleeding within the lower gut – large
(air)bacteria.
intestine, rectum and anus.
• Indicative of bleeding originating from
 Can be associated with rapid bleeding of higher up in the gut – esophagus, stomach
upper GI tract and duodenum
 evident in the stool, coating the feces, • Patient complaints odour of stool is like
presenting as red strands/streaks or dripping old /stale blood

 If due to diarrhea, stool will be watery appear

pink to red.
 B) Hereditary Non-Polyposis Colorectal Ca (HNPCC)
 Inherited mutations in mismatch repair (MMR) genes; eg; MLH1, MSH2
 usually proximal to splenic flexure
 Tend to arise from polyps which are commonly flat, with villous histology
 This syndrome is characterised by increased risk of colorectal cancer and also
cancers of the endometrium, ovary, stomach and small intestines.
 Morphology
7. Colorectal carcinoma

Epidemiology
 Commonest GIT malignancy
 Peak : age of 60-70 years old
 Chinese is more prevalent

Pathology
 Almost all tumors from adenocarcinoma
 90% from sporadic
 Little from FAP and HNPCC
 Risk factors:
 Age : > 50 years
 Genetic Predisposition
-History of CRC (personal or family)
-HPCC
 Ulcerative Colitis
 Adenomatous polyps
 Environmental Factors
Gross appearance of an opened colectomy specimen containing
 Diet- high in red meat, sugar or fat,
an invasive colorectal carcinoma and two adenomatous polyps.
low in fibre,
low in vitamin
 Alcohol/smoking
 NSAIDs
 8. Angiodysplasia

 Angiodysplasia is a vascular malformation that is a cause of

haemorrhage from the colon.
 Typically over 60 years old
 lesions are also called angiomas, haemangiomas and
arteriovenous malformations.
 occur particularly in the ascending colon and caecum of elderly
patients
 Malformations consist of dilated tortuous submucosal veins and
in severe cases the mucosa is replaced by massive dilated
deformed vessels.